Healthcare Provider Details

I. General information

NPI: 1255008462
Provider Name (Legal Business Name): JAKE T WYSIADLOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W END AVE STE 1150
NASHVILLE TN
37203-2528
US

IV. Provider business mailing address

1801 W END AVE STE 1150
NASHVILLE TN
37203-2528
US

V. Phone/Fax

Practice location:
  • Phone: 615-321-8881
  • Fax: 615-321-8874
Mailing address:
  • Phone: 615-321-8881
  • Fax: 615-321-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10378
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3768
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: